What is the recommended management for facial cellulitis in a child?

Management of Facial Cellulitis in Children

For facial cellulitis in children, first-line treatment should include oral antibiotics active against streptococci and MSSA, such as cephalexin, penicillin, or clindamycin, with clindamycin being preferred as it covers both beta-hemolytic streptococci and CA-MRSA. 1

Diagnosis and Evaluation

• Promptly identify causative pathogens (primarily beta-hemolytic streptococci and Staphylococcus aureus)
• Evaluate for systemic toxicity to determine appropriate antibiotic therapy and need for hospitalization 1
• Signs of systemic toxicity requiring further evaluation:
  • Hypotension (systolic BP <90 mmHg)
  • Tachycardia (>100 beats/min)
  • Fever or hypothermia
  • In these cases, obtain blood cultures and complete blood count with differential 1

Treatment Algorithm

1. Determine Severity and Need for Hospitalization

• Mild to Moderate (Outpatient Management):

  • No systemic toxicity
  • No hemodynamic instability
  • Good adherence to therapy expected

• Severe (Inpatient Management):

  • Presence of systemic toxicity
  • Hemodynamic instability
  • Poor adherence to therapy expected
  • Facial cellulitis with risk of complications (orbital involvement, cavernous sinus thrombosis)

2. Antibiotic Selection

For Non-Purulent Facial Cellulitis (No drainage/exudate):

• First-line: Target beta-hemolytic streptococci with:
  • Cephalexin 500mg orally 4 times daily, OR
  • Penicillin, OR
  • Clindamycin 300-450mg orally 3 times daily 1

For Purulent Facial Cellulitis (With drainage/exudate):

• First-line: Empirical therapy for CA-MRSA pending culture results:
  • Clindamycin (preferred as it covers both streptococci and CA-MRSA) 2, 1
  • Alternative options:
    • TMP-SMX (effective for purulent SSTI in children) 2
    • Doxycycline (for children >8 years old)
    • Linezolid 2

For Severe Cases Requiring Hospitalization:

• First-line:
  • Vancomycin (15-20 mg/kg/dose IV every 8-12 hours), OR
  • Clindamycin IV (600-900 mg every 8 hours) 1

3. Surgical Intervention

• For facial cellulitis associated with abscess, incision and drainage is the primary treatment 2
• Consider dental evaluation if odontogenic origin is suspected, as facial cellulitis may develop from dental issues 3, 4

4. Duration of Therapy

• Standard duration: 5-7 days 1
• May extend if infection has not improved within this period
• For complicated cases: 7-14 days 2

Special Considerations

MRSA Risk Factors

• Previous MRSA infection or colonization
• Recent antibiotic use
• Recurrent skin infections
• Close contact with MRSA-infected individuals
• In these cases, consider MRSA-active agents such as clindamycin, TMP-SMX, or linezolid 1

Cautions

• TMP-SMX is not recommended for infants younger than 2 months of age or pregnant women in the third trimester 2
• Tetracyclines (doxycycline, minocycline) should be avoided in children under 8 years due to dental staining

Prevention of Recurrence

• Identify and treat predisposing conditions (eczema, local trauma sites)
• Consider prophylactic antibiotics for children with 3-4 episodes per year 1
• Implement decolonization protocols for recurrent infections:
  • Intranasal mupirocin twice daily
  • Daily chlorhexidine washes
  • Daily decontamination of personal items 1

Clinical Pearls

• Facial cellulitis in children is most commonly caused by beta-hemolytic streptococci and Staphylococcus aureus, but can occasionally be polymicrobial 3
• Clindamycin has been shown to be effective in treating facial cellulitis of odontogenic origin in children 3
• Rare causes of facial cellulitis include Pseudomonas aeruginosa (especially in immunocompromised patients) and Candida albicans (in uncontrolled diabetic patients) 5, 6
• Early recognition and management of facial cellulitis is crucial to avoid serious complications such as orbital cellulitis or cavernous sinus thrombosis